It might surprise many that Health Minister Mark Butler has signalled that the most important challenge facing the Australian health system is not the ongoing effects of the pandemic, or monkeypox, but rather the impending crisis in general practice.
Outside of public hospitals, access to family doctors is one of the most cherished parts of our “universal” healthcare system.
Concurrently, the industrial arms of general practice and the Australian Medical Association have launched a media campaign threatening imminent closures of practices, and withdrawal of services to those who can’t pay additional out-of-pocket costs. The demands are focused on a 10% increase in the Medicare rebate for time-based services. However, there’s no evidence that increasing Medicare rebates actually leads to lower costs for patients.
In truth, new solutions should be on the table. They include a much greater focus on redistributing the division of labour between health professionals; extensive use of new digital technologies for assessment, service delivery and care coordination; support for team-based rather than fee for service-based care. Rewarding the tracking of outcomes rather than paying for each service provided should be central. Clearly, using funding mechanisms to enhance services to those most disadvantaged by age, geography or socioeconomic status has to be a national priority.
Butler has established a “strengthening Medicare” taskforce to urgently review these options. He has stated that he has already had “frank discussions with the doctors” on the need for serious reform. Consistent with his statements, the terms of reference for the review are much broader than a simple focus on more money. But this is where things get really hard.
The truth is that Australian general practice, based largely on the 1950s British model of easy access to basic care, is in rapid decline. It was conceived at a time of relatively low use of specialised medicine and technologies; few very expensive pharmaceuticals; less illness burden due to chronic disease and ageing; an emphasis on home visits and after-hours care; non-recognition of the impacts of conditions like anxiety, depression and substance misuse; easy access to a medical workforce.
In the 21st century, young doctors — and their informed and cashed-up patients — have voted with their feet. Being really good at specific things and delivering more expert care are far more attractive to young doctors. It is also what more informed patients demand. This is a worldwide phenomenon and one where digital technology is increasingly relevant. There is a massive unmet demand for better care that is more convenient, readily available, price sensitive and directly available to the customer.
Consequently, new “supply” chains of health services are well advanced. Many doctors assume that the “Uberisation” of healthcare — particularly the more straightforward aspects of primary and chronic care (think illness screening, health information, repeat prescriptions, blood test monitoring, telehealth reviews) — can’t happen. They assume government regulation, professional obstruction and public resistance will prevent it. I’m sure taxi drivers, local bank staff and hotel managers made the same wrong assumption.
This process of diversification of care pathways is well underway. Despite the howls of protest from the industrial arms of Australian medicine, a whole range of direct-to-consumer services, backed by technology platforms and a mobile medial workforce, is thriving. You can get the assessment online, doctors write scripts or referrals to specialists, and the medicine you want gets delivered in the post. No lining up in a doctor’s surgery, paying additional costs or spending time and effort on things you don’t need.
Additionally, the movement of general practitioners to more specialised forms of practice — those more rewarding financially and personally — is well advanced. Have you ever visited a GP-run clinic for dermatology, sports medicine, paediatrics, women’s health, mental health or 24/7 emergency and got a far more expert, accessible and affordable service than from a generic family practice? My family members have done exactly that and the experience has been great. That’s not to mention the extent to which GPs have moved to other less essential but financially lucrative areas like cosmetic practice.
So there is no stemming the tide away from traditional family practice. As Butler has noted, only 15% of Australian medical graduates are planning to be GPs. We will shortly run out of Australian-trained GPs as the workforce ages and retires. We are also short of specialists in many key areas like mental health.
No matter what other structural, workforce or training reforms are implemented, we will still need many more doctors — and many other health professionals (think nurse practitioners, psychologists, physiotherapists) to take over the roles previously performed by GPs.
Another important option is opening our borders to international medical and other health professionals. An emphasis on attracting those who have worked in team-based care systems would be very attractive.
The “closed shop” approach of Australian medicine has largely resembled that previously expressed by Australian pilots, namely only “Australian pilots can fly in Australian skies”. When they withdrew their services, Bob Hawke took decisive action. As Prime Minister Anthony Albanese models himself on Hawke, we may now have another occasion where such decisive action is required.
This article was edited post-publication on August 30, 2022. An earlier version of this article incorrectly referred to the Australian Medical Professionals’ Society instead of the The Australian Medical Association.
